I'm Done

[Aether2000]

Dr. Common sense, have you ever stopped to actually think before you post such gibberish? Not everyone has the capacity to declare what an entire practice will do when they do not own the practice. I intend on quitting my position at that practice, putting my money where my mouth is. Why don't you try minding your own goddamn business instead of being an interloper

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[Ducttape]

algos was wise and thoughtful enough to post about a potential game changer to how local governments are approaching opioid prescribing, and, if the pattern continues, the direct threat to all those practices that prescribe opioids. a lot to think about, and we need to confront it now rather than after we owe money or, worse yet, behind bars.

 

[Yo GabbaPentin]

Dr. Common sense, have you ever stopped to actually think before you post such gibberish? Not everyone has the capacity to declare what an entire practice will do when they do not own the practice. I intend on quitting my position at that practice, putting my money where my mouth is. Why don't you try minding your own goddamn business instead of being an interloper

Yeah I saw that one coming...

I do appreciate you posting about this and understand how disheartening, nauseating and nerve wracking it is to see the nonsense pour from these **** for brains "leaders" and attorneys. FWIW, my advise would be to give it some time before turning your world upside down over those half wits and their stupid/greedy ideas. They will likely see some change of heart after public backlash which is already starting as pharmacies are refusing to fill rx left and right.

 

[Disciple]

I think the take home point is that each of us should be thinking about diversifying our work, and figuring out how to create a successful opioid free practice, should the need arise.

 

[EtherBunny]

Maybe I'm missing something here...

1. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of chronic, nonmalignant pain beyond the 4 month mark, and the evidence up to 4 months is relatively poor.
2. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of neuropathic pain.
3. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of centralized pain disorders.
4. There is a mounting body of evidence that the long term adverse effects of systemic opioid use outweigh any potential benefits.
5. There is a significant discrepancy between what patients reports in terms of benefits from opioid use and actual benefits.
6. Long term opioid use is a risk factor for treatment failure with interventional pain procedures and certain surgeries.
7. Opioids are highly addictive, even under the best circumstances (close monitoring, etc.).
8. There is a worsening epidemic of opioid overdoses throughout the United States.
9. Death from opioid overdose is no longer viewed as just medical malpractice--it can be prosecuted as homicide. There is a legal precedent for doing so already.

And now we have lawyers extending the reach of litigation to every aspect of opioid prescribing from the manufacturers to the regulating bodies and dispensing entitities...and, lest we forget, the prescribers.

With ALL of these factors at play, why are opioids still prescribed for non-malignant pain? Algos has a rock solid justification for his decision. I wish everyone in our specialty would do the same. I genuinely want an opioid free practice, but I keep encountering huge barriers to implementing it effectively. The fundamental problem is that there are still so many pain physicians in my area who routinely prescribe opioids for every painful condition under the sun. Very frustrating. We all have to be on the same page to really turn the tide here.

Of course there will always be physicians in the community doing stupid things vis-a-vis prescribing opioids and other controlled substances. But it would be nice if every fellowship-trained, boarded pain physician across the US had the SAME practice philosophy for non-malignant pain--i.e., avoidance of systemic opioids like the plague.

 

[DrCommonSense]

Dr. Common sense, have you ever stopped to actually think before you post such gibberish? Not everyone has the capacity to declare what an entire practice will do when they do not own the practice. I intend on quitting my position at that practice, putting my money where my mouth is. Why don't you try minding your own goddamn business instead of being an interloper

You posted on a public forum whining about how dangerous it is to prescribe narcotic medications and you were "done" with prescribing them.

I responded that you should just stop prescribing them and let your referral base know you will never write another narcotic again or take any over from them.

Seems like a simple problem to solve. Dont know why you are incessantly whining in a public forum about how you won't prescribe them anymore due to "legal" risks when there is such a simple solution.

Let the people who aren't as worried prescribe those medications and take them over from the PCPs

P.S. One can't be an interloper when responding to a post on a public forum.

 

[DrCommonSense]

Maybe I'm missing something here...

1. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of chronic, nonmalignant pain beyond the 4 month mark, and the evidence up to 4 months is relatively poor.
2. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of neuropathic pain.
3. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of centralized pain disorders.
4. There is a mounting body of evidence that the long term adverse effects of systemic opioid use outweigh any potential benefits.
5. There is a significant discrepancy between what patients reports in terms of benefits from opioid use and actual benefits.
6. Long term opioid use is a risk factor for treatment failure with interventional pain procedures and certain surgeries.
7. Opioids are highly addictive, even under the best circumstances (close monitoring, etc.).
8. There is a worsening epidemic of opioid overdoses throughout the United States.
9. Death from opioid overdose is no longer viewed as just medical malpractice--it can be prosecuted as homicide. There is a legal precedent for doing so already.

And now we have lawyers extending the reach of litigation to every aspect of opioid prescribing from the manufacturers to the regulating bodies and dispensing entitities...and, lest we forget, the prescribers.

With ALL of these factors at play, why are opioids still prescribed for non-malignant pain? Algos has a rock solid justification for his decision. I wish everyone in our specialty would do the same. I genuinely want an opioid free practice, but I keep encountering huge barriers to implementing it effectively. The fundamental problem is that there are still so many pain physicians in my area who routinely prescribe opioids for every painful condition under the sun. Very frustrating. We all have to be on the same page to really turn the tide here.

Of course there will always be physicians in the community doing stupid things vis-a-vis prescribing opioids and other controlled substances. But it would be nice if every fellowship-trained, boarded pain physician across the US had the SAME practice philosophy for non-malignant pain--i.e., avoidance of systemic opioids like the plague.

Basically your referring docs won't send you patients unless you take over their narcotic management and will send them to your competitors who are willing to do so.

Sounds like your referral base doesn't agree with your perspective on the opioid issue since they are mostly only willing to refer patients to the pain docs that are willing to write narcotic meds.

Maybe you should be frustrated with referring docs that only will send you patients if you manage their narcotics. Why not give them this presentation?

If the referral docs won't prescribe narcotic meds and are willing to send you patients who won't be prescribed narcotic medications, you wouldn't have this issue.

 

[drpainfree]

I have to agree with DrCommonSense. It's not matter of what you want to do or not, it's a matter of what's feasible in a private practice. When I was working in VA during my fellowship, my fellowship co-director had a strict policy of no opioid prescription. Can you imagine that? No opioid prescription in VA. But hey, he didn't care, because he couldn't be fired. Instead he focused his energy advocating opioid-induced hyperalgesia as a reason not prescribing opioid.

In private practice, you are always balancing a reasonable referral from a reasonable PCP vs. opioid dumbs from overly-prescribing PCP. You can always cut out referrals from the latter, just don't expect anymore business from him.

It's your decision. Pretty simple to stop prescribing opioids all together. You just have to diversify enough in a private practice to survive. I think most of us on this forum would not go either extreme.

 

[Aether2000]

You cannot make such decisions to "prescribe" or "not prescribe" any opioids unless you own the practice. Your only option in such situations is to leave the practice, which is exactly what I am doing.

 

[bronchospasm]

So here is my take, FWIW,

In my limited experience,

1/3 of your patients will be a slam dunk and will respond very well to conservative management like physical therapy, Chiropractic care, muscle relaxants, neuropathics, NSAIDS, home exercise programs and interventional procedures, stims etc. You will never see these patients again. They will do free marketing for you.

1/3 will get better between 40-60 percent and still have some underlying issues requiring TPI’s, re referral to therapy, periodic epidurals, repeat RFA’s and slew of other medications maybe occasional tramadol etc,

1/3 will be the non responders, who fail everything, nothing helps, nothing works type of patients. These are typically your difficult to deal with patients. These are typically patients who have had multiple surgeries, tried every Interventional procedures and have not responded well to these or have had temporary relief. From this group, If you weed out the mod-severely depressed, ADHD, Bipolar, drug seeking and inappropriately managed patients, and are not just take over prescribing, you will be left with very few patients who actually Benifit from COT.

And if you limit yourself to 15-20 MED doses and not escalate, I doubt it that anyone will come after you if you do the right thing. I have a handful of patients who are on COT

 

[myrandom2003]

have zero legal expertise other than what I see on Suits and other legal shows like night court.

But, once the first case gets thrown out, won't that just essentially knock down all the other cases unless they can make a different argument then you rx'd opioids?
can all named defendents file a counter suit?

good luck to everyone with a broken bone, hospice, and surgical patients trying to manage post op pain.

 

[NJPAIN]

So here is my take, FWIW,

In my limited experience,

1/3 of your patients will be a slam dunk and will respond very well to conservative management like physical therapy, Chiropractic care, muscle relaxants, neuropathics, NSAIDS, home exercise programs and interventional procedures, stims etc. You will never see these patients again. They will do free marketing for you.

1/3 will get better between 40-60 percent and still have some underlying issues requiring TPI’s, re referral to therapy, periodic epidurals, repeat RFA’s and slew of other medications maybe occasional tramadol etc,

1/3 will be the non responders, who fail everything, nothing helps, nothing works type of patients. These are typically your difficult to deal with patients. These are typically patients who have had multiple surgeries, tried every Interventional procedures and have not responded well to these or have had temporary relief. From this group, If you weed out the mod-severely depressed, ADHD, Bipolar, drug seeking and inappropriately managed patients, and are not just take over prescribing, you will be left with very few patients who actually Benifit from COT.

And if you limit yourself to 15-20 MED doses and not escalate, I doubt it that anyone will come after you if you do the right thing. I have a handful of patients who are on COT

Although I think that I have yet (in 25 years) to see a patient who truly has a pharmacological benefit from COT, rather than just convincing themselves that they can't function without opioids, a "handful" of homegrown (patients in whom YOU initiate) COT patients may make SOME sense in SOME cases. The problem develops when you open your doors to taking on the COT patients of everyone else. In my area every PCP and pills for shots "pain doctor" has now backed out of prescribing leaving many, many patient scrambling. Just last week a PM&R pain doc employed by the primary care group across the street told his patients that he is leaving the practice. They are all calling me now. Every 2-3 month we have an event like this. If I opened my doors to these people I would have acquired 200-300 COT patients this year. I would have a lot of PCPs in that group who would be really happy with me and perhaps a lot more decent patients from them. In exchange I would have to paint a target on MY back and deal with the crap that comes along with the COT patients. I also don't think that "doing the right thing" protects you at all especially when it comes to taking on those monsters that other docs have created.

 

[bronchospasm]

Although I think that I have yet (in 25 years) to see a patient who truly has a pharmacological benefit from COT, rather than just convincing themselves that they can't function without opioids, a "handful" of homegrown (patients in whom YOU initiate) COT patients may make SOME sense in SOME cases. The problem develops when you open your doors to taking on the COT patients of everyone else. In my area every PCP and pills for shots "pain doctor" has now backed out of prescribing leaving many, many patient scrambling. Just last week a PM&R pain doc employed by the primary care group across the street told his patients that he is leaving the practice. They are all calling me now. Every 2-3 month we have an event like this. If I opened my doors to these people I would have acquired 200-300 COT patients this year. I would have a lot of PCPs in that group who would be really happy with me and perhaps a lot more decent patients from them. In exchange I would have to paint a target on MY back and deal with the crap that comes along with the COT patients. I also don't think that "doing the right thing" protects you at all especially when it comes to taking on those monsters that other docs have created.

Honestly, if you practise good clean medicine, it will be difficult for anyone to come after you.
They will go after the top prescribers in the area.

If they want to sue me for writing 10 scripts a month. They are wasting their time.

 

[smq123]

Honestly, if you practise good clean medicine, it will be difficult for anyone to come after you.
They will go after the top prescribers in the area.

If they want to sue me for writing 10 scripts a month. They are wasting their time.

That's an interesting point. Who ARE the top prescribers in the area? I used to practice in Pinellas County (family medicine) and I'm not convinced that the most prolific prescribers are all pain management. Sure, I'm sure that some are. But the oncologists write a ton of prescriptions for narcotics, and I can guarantee that none of them are checking E-FORCSE (= the Florida PDMP) or doing any other sort of due diligence. The worst drug seekers that I remember were cancer patients. ("When I opened my box of fentanyl patches, they were all stuck together and not usable. My oncologist is out of town. I'm sure that Dr. SMQ won't mind writing me a new prescription for my fentanyl patches? She knows that I have CANCER, right?") Ortho also writes a ton of prescriptions, although I'm sure that that has gone down somewhat over the past few years.

I feel like the "We're going to go after prescribers, too!" is a good sound bite on TV, particularly in Florida. But I think that the picture is a lot more complicated than they realize.

Plus, there are still a lot of terrible doctors in Pinellas - quasi-retired physician giving out Subutex AND Klonopin to the same patient. Semi-retired plastic surgeon giving 300 tablets of dilaudid to a patient with pseudotumor cerebri. Shady pain management doctor giving a 30 year old girl MS Contin for "scoliosis." If they go after physicians, they'll have their hands full with the most egregious cases.

 

[Doctodd]

just read (maybe fake news) that they are going after the Joint Commission in WV because they recommended opioid guidelines......remember the 5th vital sign bla bla bla?

Scope of opioid lawsuits widens to include influential hospital accreditor

Hey algos......maybe you could visit all the big law firms in your area for a free consultation about something unrelated...then they cant sue their own client.

 

[lobelsteve]

Algos is still the man. He should be hired by all these law firms to assist in the lawsuits.

Look for opportunity.

 

[Aether2000]

Lol...no no no...I am pro-physician and will not give any help to the vampires

 

[VA Hopeful Dr]

Lol...no no no...I am pro-physician and will not give any help to the vampires

I don't know, I could get onboard with a lawsuit against the Joint Commission

 

[drusso]

Lol...no no no...I am pro-physician and will not give any help to the vampires

I'd like to see a class action (the class being employed MD's) sue every employer that ever used "pain" or "patient satisfaction" as an input into a bonus or compensation scheme. That would be a juicy one!

 

[emd123]

If anyone is considering stopping opiate prescribing, by all means, do it. I'll never try to convince anyone not to and I likely will someday, too, as I've been lowering the MME/day I've been prescribing over time anyways.

That being said, and in the interest in talking some people off the ledge, if these suits are going to have any legs against doctors following the standard of care and prescribing opiates for legitimate medical need in low to moderate doses, and in good faith, they'll need to sue the Federal government, DEA, FDA and all 50 states drug control agencies and all 50 medical boards, all of whom as a matter of official policy and law, have stated and currently still state, that opiates have legitimate medical use. Not only do they state opiates have legitimate medical use, they give us explicit instructions how to do do so, and encourage the treatment of pain as part of our duties. So, the lawyers can go ahead and try, as they always do, just like they sue when people spill coffee on themselves and drunks fall on train tracks. But while they're at it, they can sue the Feds, the States, and the medical boards. That's where the real money is, anyways.

But if they really wants a persuadable case with traction, they can convince the Feds to make opiates schedule I, ie "No legitimate medical use" if they want to be effective in suing docs for prescribing them within the standard of care. And when they do that, I'll gladly stop prescribing any and all opiates (I may stop, anyways). But until they do that, they don't have a leg to stand on, if they're only argument is, "You prescribed opiates the right way, the way the DEA, FDA, CDC and medical boards told you to."

Again, I'd love it if these same lawyers can use their muscle to get opiates moved to Schedule I, and I'll gladly stop any and all opiate prescribing. But until that happens, they're going to have a tough road to hoe, getting over that 800 lb gorrilla in the room, that is the Federal and state governments' sanctioning and endorsing of opiate as legitimate medications when their own standards of care are followed.

 

[jsaul]

Algos

When did you leave Indiana and to go work for some other docs in Florida? You had your own practice there in indiana.

 

[emd123]

Pinellas County Commission considers potential opioid litigation

Wait. Reading this again, it seems like just referring to a copycat suit like big suit against Pharma that included a handful of big name docs from the '80s and '90s, like Portenoy, Fine, Fishman & Webster.

Here's another one, from the Cleveland area. Again, suing the drug co's and only those same Pain celebro-docs.

Dayton, Lorain to sue opioid makers, drug distributors and doctors

"The lawsuit names as defendants:

• five opioid manufacturers: Purdue Pharma, Endo Health Solutions, Teva Pharmaceutical Industries and subsidiary Cephalon, Johnson & Johnson and subsidiary Janssen Pharmaceuticals and Allergan, formerly known as Actavis.
• three distributors: McKesson Corporation, AmerisourceBergen Corporation and Ohio-based Cardinal Health.
• four physicians associated with the drug companies: Russell Portenoy, Perry Fine, Scott Fishman and Lynn Webster."

Again, I have prescribing opiates as much as anyone, and need to monitor this, but I'm not sure how you get from those 4 guys getting sued (who've all had very high profile and profitable connections to drug companies), to calamity for ever doc that's every written an opiate Rx within the standard of care.

 

[Aether2000]

In the video from the Pinellas County Commissioners meeting, they specifically discussed suing doctors prescribing opioids and how to get around the current ordinance to allow them to do so. This was not necessarily reported by the news but was the topic of discussion by the Commissioners themselves. I spent hours watching these videos. It is amazing what goes on and politics that we are incapable of knowing or understanding since we are only at the behest of what news organizations elect to report.

Btw I left Indiana to retire and thaw out in Florida but decided to work for an already existing interventional practice that prescribes opioids for long term patients but no new patients for the past two years. I did not want the headache of establihing a new practice in Florida. The doses for those receiving opioids are low and in limited numbers.

 

[DOctorJay]

how did the other doc respond when you shared this information with him? any planned changes there?

 

[Blitz2006]

That's an interesting point. Who ARE the top prescribers in the area? I used to practice in Pinellas County (family medicine) and I'm not convinced that the most prolific prescribers are all pain management. Sure, I'm sure that some are. But the oncologists write a ton of prescriptions for narcotics, and I can guarantee that none of them are checking E-FORCSE (= the Florida PDMP) or doing any other sort of due diligence. The worst drug seekers that I remember were cancer patients. ("When I opened my box of fentanyl patches, they were all stuck together and not usable. My oncologist is out of town. I'm sure that Dr. SMQ won't mind writing me a new prescription for my fentanyl patches? She knows that I have CANCER, right?") Ortho also writes a ton of prescriptions, although I'm sure that that has gone down somewhat over the past few years.

I feel like the "We're going to go after prescribers, too!" is a good sound bite on TV, particularly in Florida. But I think that the picture is a lot more complicated than they realize.

Plus, there are still a lot of terrible doctors in Pinellas - quasi-retired physician giving out Subutex AND Klonopin to the same patient. Semi-retired plastic surgeon giving 300 tablets of dilaudid to a patient with pseudotumor cerebri. Shady pain management doctor giving a 30 year old girl MS Contin for "scoliosis." If they go after physicians, they'll have their hands full with the most egregious cases.

Well according to this paper:

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. - PubMed - NCBI

Only 5% of all opioid prescriptions in 2012 were by Pain Physicians. 44% of scripts were by PMDs (FPs/GPs/Internists).

Some food for thought.

 

[emd123]

Well according to this paper:

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. - PubMed - NCBI

Only 5% of all opioid prescriptions in 2012 were by Pain Physicians. 44% of scripts were by PMDs (FPs/GPs/Internists).

Some food for thought.

This would explain why the focus of the CDC recommendations is explicitly directed at Primary Care.

 

[Blitz2006]

This would explain why the focus of the CDC recommendations is explicitly directed at Primary Care.

Yep, straight from the CDC website:

Prescribing Data | Drug Overdose | CDC Injury Center

"Prescribing rates are highest among pain medicine (49%), surgery (37%), and physical medicine/rehabilitation (36%). However, primary care providers account for about half of opioid pain relievers dispensed."

 

[emd123]

Maybe I'm missing something here...

1. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of chronic, nonmalignant pain beyond the 4 month mark, and the evidence up to 4 months is relatively poor.
2. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of neuropathic pain.
3. The current body of scientific evidence does NOT support the use of systemic opioids in the treatment of centralized pain disorders.
4. There is a mounting body of evidence that the long term adverse effects of systemic opioid use outweigh any potential benefits.
5. There is a significant discrepancy between what patients reports in terms of benefits from opioid use and actual benefits.
6. Long term opioid use is a risk factor for treatment failure with interventional pain procedures and certain surgeries.
7. Opioids are highly addictive, even under the best circumstances (close monitoring, etc.).
8. There is a worsening epidemic of opioid overdoses throughout the United States.
9. Death from opioid overdose is no longer viewed as just medical malpractice--it can be prosecuted as homicide. There is a legal precedent for doing so already.

And now we have lawyers extending the reach of litigation to every aspect of opioid prescribing from the manufacturers to the regulating bodies and dispensing entitities...and, lest we forget, the prescribers.

With ALL of these factors at play, why are opioids still prescribed for non-malignant pain? Algos has a rock solid justification for his decision. I wish everyone in our specialty would do the same. I genuinely want an opioid free practice, but I keep encountering huge barriers to implementing it effectively. The fundamental problem is that there are still so many pain physicians in my area who routinely prescribe opioids for every painful condition under the sun. Very frustrating. We all have to be on the same page to really turn the tide here.

Of course there will always be physicians in the community doing stupid things vis-a-vis prescribing opioids and other controlled substances. But it would be nice if every fellowship-trained, boarded pain physician across the US had the SAME practice philosophy for non-malignant pain--i.e., avoidance of systemic opioids like the plague.

If points 1-9 are all true, and there are no exceptions in which opiates benefit a patient more then harm them, then people should be arguing for banning them, and moving them to schedule I. All the other guidelines-focus approaches are pissing in the wind. If there is any, I mean ANY, opening left in these guidelines for 'exceptions' then the drugs will be prescribed. Every patient thinks they're an exception, and every prescribing doc, thinks their patient's are as well. All patients will also say, there pain is 'acute,' because although it was their chronically, and may continue to be, their acutely feeling it, today.

So, if you're going to argue that opiates have no legitimate medical use, that's fine. Start also, arguing to ban them and make them schedule I. Because everything else is intellectually dishonest, and likely as futile as using a squirt gun to fight a raging inferno.

Let's be honest, and consistent: Either opiates have legitimate medical use in some cases for chronic pain, or the should be banned except for in hospital use or beyond 6 weeks after a surgery or fracture.

Choose.

 

[hyperalgesia]

If points 1-9 are all true, and there are no exceptions in which opiates benefit a patient more then harm them, then people should be arguing for banning them, and moving them to schedule I. All the other guidelines-focus approaches are pissing in the wind. If there is any, I mean ANY, opening left in these guidelines for 'exceptions' then the drugs will be prescribed. Every patient thinks they're an exception, and every prescribing doc, thinks their patient's are as well. All patients will also say, there pain is 'acute,' because although it was their chronically, and may continue to be, their acutely feeling it, today.

So, if you're going to argue that opiates have no legitimate medical use, that's fine. Start also, arguing to ban them and make them schedule I. Because everything else is intellectually dishonest, and likely as futile as using a squirt gun to fight a raging inferno.

Let's be honest, and consistent: Either opiates have legitimate medical use in some cases for chronic pain, or the should be banned except for in hospital use or beyond 6 weeks after a surgery or fracture.

Choose.

I think the arguments are again population vs individual health. From a population health standpoint, it's reasonable to argue that, when taking into consideration all opioids that are prescribed by docs for chronic pain, more harm has come to the population than benefit.

But it would be really hard to say that NOT A SINGLE PATIENT is better off with ANY opioids for chronic pain.

 

[clubdeac]

In the video from the Pinellas County Commissioners meeting, they specifically discussed suing doctors prescribing opioids and how to get around the current ordinance to allow them to do so. This was not necessarily reported by the news but was the topic of discussion by the Commissioners themselves. I spent hours watching these videos. It is amazing what goes on and politics that we are incapable of knowing or understanding since we are only at the behest of what news organizations elect to report.

Btw I left Indiana to retire and thaw out in Florida but decided to work for an already existing interventional practice that prescribes opioids for long term patients but no new patients for the past two years. I did not want the headache of establihing a new practice in Florida. The doses for those receiving opioids are low and in limited numbers.[/QUOTE
Please don't tell me you work for Coastal Spine and Pain

 

[Aether2000]

It does make me wonder if our own pain societies failed in this respect. They could have issued some guidelines on who is an appropriate candidate but that would require agreement in a group of members and it is not clear that any such a agreement would be possible. I certainly do not favor banning opioids for all chronic pain patients, however a fluid document that could be altered depending on data and new studies could specify who should in general not be a candidate for chronic opioids or what restrictions should be placed on opioid prescribing based on the mental health and physical health of patients

 

[lobelsteve]

Forsyth County, Georgia just announced they are considering joining tbe hunt. Presented by local law firms to cinvince county to sue everyone.

 

[Aether2000]

Metastatic lawyers

 

[DrCommonSense]

Forsyth County, Georgia just announced they are considering joining tbe hunt. Presented by local law firms to cinvince county to sue everyone.

Lawyers gonna lawyer

I love how liberal socialists are all about "single payer systems like in Europe" but never speak about how there is a lack of lawsuits under those systems.

 

[Ducttape]

isn't that an advantage, not having frivolous lawsuits?

 

[LADoc00]

Today Pinellas County in Florida, despite the most restrictive ordinances anywhere in the country for prescribing opioids, has elected to begin filing civil lawsuits against manufacturers, distributors, and prescribers of opioids to recapture the county paid cost of addiction treatment, counseling, medical examiner and lab costs in cases of autopsy due to opioid overdose, and an array of other related costs. They are specifically including "doctors that prescribe opioids" in the targeting and have now issued a request for proposals by regional law firms to go after the monetary assets of physicians. They plan to begin "data mining" to discover who is prescribing opioids. That is the end of opioid prescribing for me, even low amounts of opioids.

Im actually watching this with much interest. I agree though, this is a nightmare for MDs in this market space simply beyond imagining until now. My own local buddy doing this is basically hosed, I may actually advise him to flee the country.

 

[Yo GabbaPentin]

Forsyth County, Georgia just announced they are considering joining tbe hunt. Presented by local law firms to cinvince county to sue everyone.

It's just a monkey see monkey do kind of thing. Kind of like how schools were closing several years back for days at a team to clean out all of the mrsa. The limits to the stupidity behind government and public knows no bounds.

 

[emd123]

isn't that an advantage, not having frivolous lawsuits?

It's an advantage for the country, but not an advantage for the trial lawyers and their politicians who typically donate in much greater numbers to the Democrats. Although I do think it's fair to say both parties are beholden to their cronies in the law profession, since most in government have a law background. That being said, most of the time when I see a push for tort reform, it seems to come from the GOP side, and rarely if ever from the Dem side. But in the end, neither party really wants to limit the predatory medical malpractice system we have, otherwise they would have done it, and neither party when in control, neither Dem Congress during Obama, nor GOP congress during early Bush or now Trump, have made much effort to do so.

 

[emd123]

Forsyth County, Georgia just announced they are considering joining tbe hunt. Presented by local law firms to cinvince county to sue everyone.

"Sue everyone" is not a valid or effective legal strategy.

If so, good luck suing every doctor who sees alive patients. They'll have to sue every PCP, internist, FP, PA, NP, since that's who writes the majority of opiate Rx's. Then they'll have to sue every surgeon, ER doc, ortho, ortho-spine, urgent care, neurosurg, urologist, Pain MD who's ever written an opiate, and on down the line. And suing just to sue is not an effective plan, either. They have to prove actual damages. The claim can't be, "We're suing you just because you did something we don't like," and expect to be effective.

They can't sue, and expect to win, for prescribing to a patient that says, "Oh yeah. He prescribed me pain medicines for 10 years. Helped my back. I couldn't walk without it. Thank God he did or I'd have been screwed."

Over the years they've tried to sue the tobacco companies in response to cancer deaths, the gun makers due to gun deaths, the alcohol companies due to alcohol deaths, the car makers due to car crash deaths, and the silicone breast implant companies due to silicone breast implant complications. Some of those efforts have been more successful than others. But have they sued every tobacco shop, gun shop, winery, car salesman, or breast implant surgeon out of business?

No.

Although we like to think of ourselves as having 'deep pockets' because we get sued and have insurance policies, we are not the deep pockets in this game. The drug companies are. That's where they're likely to focus most of their efforts. We're not even close to that same level. They can get billions from them, much easier than trying to sue thousands of individual doctors.

Also, it's worth keeping in mind, that if the politicians want to push us to the extent that no one prescribes anyone opiates, there's going to be hell to pay that I don't think they've even considered. I know for a fact, plenty of them are elderly with chronic pain problems. I'm sure there's more than a few on opiates. Plenty of their family members are likely to have chronic pain problems and be on an opiate. And boatloads of their constituents are for sure. So if they want to push us to the point where there's a de facto ban on opiates, where they're legal but none of us prescribe them to anyone, due to fear of retribution, then they need to be careful what they wish for. Because if they want opiates gone, they get their wish, and their own families or constituents are in agony, all of a sudden it's they who are the deniers of opiates, and they're going to feel the wrath that we've felt all along, with angry mobs of opiate seeking patients in pain and withdrawal at their rallies and congressional offices. And we'll just be plugging along in our 3-day-per-week, injection-only practices, maybe making a little bit less money, but much, much, happier.

 

[Ducttape]

I think you are being overtly complacent. again, as noted, what is being contemplated are civil suits which do not require the burden of evidence. you can find millions of people who will be willing to state that the opioid medications that they were prescribed caused them to become addicted... because they can use that cash to buy more drugs.

I get to watch about 1/2 an hour of television at night after the kids go to bed. in the past week, I have seen lawyer ads for:
Hip replacement gone bad
hernia mesh
transvaginal mesh
bariatric surgery
Invokana
Xarelto
Talcum Powder

and local lawyers don't want to hit the big companies, because they bite back with all the money they have. middle ground, people who want to continue to work - ie doctors - are prime targets.

in the examples you named - there was the burden of proof that something was done wrong. if what is being threatened comes in to play, then there isn't that burden. only the supposition.

 

[emd123]

I think you are being overtly complacent. again, as noted, what is being contemplated are civil suits which do not require the burden of evidence. you can find millions of people who will be willing to state that the opioid medications that they were prescribed caused them to become addicted... because they can use that cash to buy more drugs.

I get to watch about 1/2 an hour of television at night after the kids go to bed. in the past week, I have seen lawyer ads for:
Hip replacement gone bad
hernia mesh
transvaginal mesh
bariatric surgery
Invokana
Xarelto
Talcum Powder

and local lawyers don't want to hit the big companies, because they bite back with all the money they have. middle ground, people who want to continue to work - ie doctors - are prime targets.

in the examples you named - there was the burden of proof that something was done wrong. if what is being threatened comes in to play, then there isn't that burden. only the supposition.

1-All of these that you mentioned, are all class action lawsuits against the drug and equipment companies, not individual suits against doctors that put them in. Cardiologists are still prescribing blood thinners, surgeons are still putting in mesh, surgeons are still doing obesity surgery, and ortho's are still putting in hips. I don't see any of them panicking about the sky falling, because lawyers and lawyering.

2-Civil suits always require a 'preponderance of evidence.' You can't win any lawsuit without evidence. That's just nonsense. Yes, the standard is lower in civil suits and proof does not have to be 'beyond a shadow of a doubt,' however, to claim that all of a sudden lawyers have found a way to sue people and win, without any significant level of evidence, is just silly. Medical malpractice suits are civil suits, and those are tough cases for lawyers to win.

Again, if all this leads to me and all of the rest of us no longer prescribing opiates, I say, "Great!" I've already lowered the max MME/day I will prescribe twice already, and I'll gladly do it again. I'll gladly lower it again to 60 MME/day, or 30 MME/day, or preferably, 0 MME/day someday, and maybe sooner, rather than later. However, I'm not going to panic because lawyers are being lawyers, throwing turds up against the wall to see which will stick.

 

[drpainfree]

Well according to this paper:

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. - PubMed - NCBI

Only 5% of all opioid prescriptions in 2012 were by Pain Physicians. 44% of scripts were by PMDs (FPs/GPs/Internists).

Some food for thought.

anyone has this article to share?

 

[101N]

Yea but...

Pain Med. 2017 Mar 6. doi: 10.1093/pm/pnx027. [Epub ahead of print]
Opioid Prescriptions by Specialty in Ohio, 2010-2014.
Weiner SG1, Baker O1, Rodgers AF2, Garner C3, Nelson LS4, Kreiner PW5, Schuur JD1.
Author information

Abstract
BACKGROUND. :
The current US opioid epidemic is attributed to the large volume of prescribed opioids. This study analyzed the contribution of different medical specialties to overall opioids by evaluating the pill counts and morphine milligram equivalents (MMEs) of opioid prescriptions, stratified by provider specialty, and determined temporal trends.

METHODS. :
This was an analysis of the Ohio prescription drug monitoring program database, which captures scheduled medication prescriptions filled in the state as well as prescriber specialty. We extracted prescriptions for pill versions of opioids written in the calendar years 2010 to 2014. The main outcomes were the number of filled prescriptions, pill counts, MMEs, and extended-released opioids written by physicians in each specialty, and annual prescribing trends.

RESULTS. :
There were 56,873,719 prescriptions for the studied opioids dispensed, for which 41,959,581 (73.8%) had prescriber specialty type available. Mean number of pills per prescription and MMEs were highest for physical medicine/rehabilitation (PM&R; 91.2 pills, 1,532 mg, N = 1,680,579), anesthesiology/pain (89.3 pills, 1,484 mg, N = 3,261,449), hematology/oncology (88.2 pills, 1,534 mg, N = 516,596), and neurology (84.4 pills, 1,230 mg, N = 573,389). Family medicine (21.8%) and internal medicine (17.6%) wrote the most opioid prescriptions overall. Time trends in the average number of pills and MMEs per prescription also varied depending on specialty.

CONCLUSIONS. :
The numbers of pills and MMEs per opioid prescription vary markedly by prescriber specialty, as do trends in prescribing characteristics. Pill count and MME values define each specialty's contribution to overall opioid prescribing more accurately than the number of prescriptions alone.

 

[Blitz2006]

Yea but...

Pain Med. 2017 Mar 6. doi: 10.1093/pm/pnx027. [Epub ahead of print]
Opioid Prescriptions by Specialty in Ohio, 2010-2014.
Weiner SG1, Baker O1, Rodgers AF2, Garner C3, Nelson LS4, Kreiner PW5, Schuur JD1.
Author information

Abstract
BACKGROUND. :
The current US opioid epidemic is attributed to the large volume of prescribed opioids. This study analyzed the contribution of different medical specialties to overall opioids by evaluating the pill counts and morphine milligram equivalents (MMEs) of opioid prescriptions, stratified by provider specialty, and determined temporal trends.

METHODS. :
This was an analysis of the Ohio prescription drug monitoring program database, which captures scheduled medication prescriptions filled in the state as well as prescriber specialty. We extracted prescriptions for pill versions of opioids written in the calendar years 2010 to 2014. The main outcomes were the number of filled prescriptions, pill counts, MMEs, and extended-released opioids written by physicians in each specialty, and annual prescribing trends.

RESULTS. :
There were 56,873,719 prescriptions for the studied opioids dispensed, for which 41,959,581 (73.8%) had prescriber specialty type available. Mean number of pills per prescription and MMEs were highest for physical medicine/rehabilitation (PM&R; 91.2 pills, 1,532 mg, N = 1,680,579), anesthesiology/pain (89.3 pills, 1,484 mg, N = 3,261,449), hematology/oncology (88.2 pills, 1,534 mg, N = 516,596), and neurology (84.4 pills, 1,230 mg, N = 573,389). Family medicine (21.8%) and internal medicine (17.6%) wrote the most opioid prescriptions overall. Time trends in the average number of pills and MMEs per prescription also varied depending on specialty.

CONCLUSIONS. :
The numbers of pills and MMEs per opioid prescription vary markedly by prescriber specialty, as do trends in prescribing characteristics. Pill count and MME values define each specialty's contribution to overall opioid prescribing more accurately than the number of prescriptions alone.

So 3% of opioid scripts in Ohio was by Anesthesiology/Pain?